Blog, Shoulder

Shoulder and Rotator Cuff Injury: Beyond Strains and Tears – A Holistic Approach to Recovery

By Dr. Joseph Tanti

By Dr. Joseph Tanti

October 21, 2023

Are you tossing and turning in your sleep?

Cant find a comfortable position to get into because your shoulder is keeping you awake?

Finding normal tasks more and more difficult to do… Washing your hair, getting dressed, and reaching into the backseat cause a sharp pain?

These problems could be caused by an injury to your rotator cuff. 

Rotator cuff injuries make up the majority of shoulder injuries. While some  are traumatic - from a fall, collision, or sudden movement - many times they are more gradual.

The “I didn’t do anything” type of injury.

The problem with rotator cuff injuries is that they don’t simply ‘get better on their own”. In fact, typically when left alone, they get worse!

Sure the pain may go…but over time, if you don’t address the problem, it is going to bite you back ten times over. How do I know?

I see it every single day in my office.

So if you are serious about solving your shoulder problem for good, you’ve come to the right place! Just keep reading.

Understanding Rotator Cuff and Shoulder Injury

To understand rotator cuff injuries, we must first understand the shoulder girdle and how the shoulder works. As one of the most mobile joints in the body, the shoulder is a bit complicated.

This mobility allows lets us do wonderful things!  Cartwheels, throwing balls, playing sports, picking up objects or people, reaching for the cookies on the top shelf, and more.

As a trade off for this mobility, the shoulder is inherently less stability. And there are a lot of muscles involved with shoulder movement! The rotator cuff is comprised of:

1)Supraspinatus, 2) Infra spinatus, 3)Teres minor and 4) Subscapularis

However there are other muscles involved with the entire shoulder girdle as well. Here they are:

  • Trapezius
  • levator scapulae
  • Scalenes (posterior, middle, anterior)
  • Rhomboids (major and minor)
  • Latissimus dorsi
  • Teres major
  • Deltoid (anterior, lateral, posterior fibres)
  • Pectoralis major
  • Pectoralis minor
  • Serratus anterior
  • Biceps brachii
  • Coracobrachialis
  • Triceps brachii 
  • Subclavius
  • Omohyoid
  • Depending how you count, that is 19-24 muscles that attach to just the scapula. That’s a lot of muscle!Of course they all work in unisync with other areas of the body as well, which I wont get into here for sake of simplicity. 

    It's important to remember, if you have a problem with your shoulder, you are likely eventually going to have a problem with your upper back and your neck. 

    What Does The Rotator Cuff Do?

    The main role of the rotator cuff is to keep the humerus (your arm bone) in the glenoid fossa and to keep it stable. It acts almost like a suction cup, keeping the head of the humerus intact and congruent with the glenoid fossa. 

    The glenoid fossa is similar to the top of a golf tee. And the head of the humorous is like a golf ball. While you are moving your arm around, something needs to hold that ball on the tee.

    Golf Ball sitting on a tee

    Can't hold the ball on the tee if you moved the tee around...the rotator cuff muscles keep the arm intact with the glenoid fossa (like holding the ball onto the tee)

    That is the primary role of the rotator cuff. Although there are other actions of the rotator cuff - the Supraspinatus  lifts the arm up to the side, subscapularis internally rotates the humerus, and infraspinatus and teres minor externally rotate the humerus -  but their main role is in stabilizing the glenohumeral joint in all ranges of motion.

    An injury to the one of these muscles, as you can imagine, may potentially destabilize this joint. This 'unstable environment' makes other shoulder conditions more likely. Examples include biceps tendinopathy, bursitis, or "impingement syndrome". 

    Rotator Cuff Sprains, Strains and Tears

    There are several different types of tendonitis, muscular and tendon injuries.  They range from grade one to grade three strains.

    Or more simply, minor injuries to the muscular and tendons structure all the way up to a full thickness tear. 

    Tears can range in size from either obviously, tiny, microscopic to full thickness. Each of these injuries are on a continuum, if you will. Full tears can be quitesevere, and minor strains are more minor. 

    However they can all be quite debilitating. These occur for a couple different reasons. The first and most obvious is due to trauma. If you fall down on an outstretched arm (we call these FOOSH injuries), or you fall on your shoulder, or you're in a car accident holding on to the steering wheel, or you pull something really heavy and you feel a sudden pain. 

    Theses senecios  can obviously cause damage to the cuff. The more common types of injuries however, are the “I didn't do anything” type of injury. 

    These are due to repetitive micro trauma.  Gradual stress and strain builds up over time until eventually you do one thing that you've done a million times before and then that's enough to put excessive load through the cuff causing an injury.

    Lets Meet Sarah

    The following is a hypothetical situation that you that you may be able to relate with. Let's take a peek. Sarah injured her shoulder. She's a successful businesswoman, outdoor enthusiast and who has been dealing with minor shoulder issues for quite some time. Lately she has been finding that her shoulder is waking her up at night, and it can be difficulty to find a comfortable position. Sometimes doing her hair can be quite a chore. It hasn't been that bad for the most part, just here and there. That is until recently.

    Woman out hiking dealing with shoulder pain

    Over the past few weeks at the gym she felt a bit of a pain in her shoulder. It wasn't that bad at first. Then over the next few days it started getting worse. Now Sarah is waking  up every night with a sharp stabbing pain, and dull ache.

    It is starting to impact her quality of life.

    Getting dressed is a chore. She hasn't been to the gym since. Even doing the dishes, driving, and reaching in the backseat really become difficulty and painful.

    The constant pain is really affecting her! She can't do the activities she likes. And worse, she doesn't know if she is able to take that trip she has been planning for for months!

    Does your Rotator Cuff Relate? 

    Now in order to solve Sarah's problem, first need to come up with a diagnosis. In the following section I'm going to go over an examination of a shoulder and highlight some key findings that Sarah may be may have.

    Here is a video of me performing a basic examination for the rotator cuff. There are more specialized tests, and nuanced changes I would do in person, depending on the situation. However this gets the point across.

    After our examination of Sarah, we need to determine if we need to send her for imaging.

    When do you send for diagnostic imaging?

    The purpose of imaging is to get a clearer picture of the tissues. We do this if a potential finding on imaging will change our course of treatment, or provide a more clear diagnosis. 

    Some of the possible reasons to do it just send for imaging include:

    A full thickness tear, these may require surgery.

    If it's partial width, partial thickness, oftentimes those don't require surgery.

    If the pain is persisting and not improving with with treatment then imaging is indicated. 

    Ultrasound is good for seeing the soft tissues and pretty accessibleMRI is the gold standard for imaging of the shoulder, however it is often cost prohibitive and there is a much longer wait period in Alberta for MRI.

    Is Sarah's Rotator Cuff Injury A Tear?

    In Sarah's case after her examination, and the nature of her injury we were suspecting a possibility of a tear due to the traumatic nature of her injury, and her inability to lift her arm over 30degrees, along with  significant shrugging when moving her arm. So I sent her for imaging. It is also important to note that she had persistent pain for quite some time and then the traumatic onset after working out.

    Some of the tests identified a high likelyhood of a tear, so we sent her for X-Ray and Ultrasound. Luckily for Sarah, there were no large tears. However, there was were small, 6mm partial thickness tearing in her supraspinatus and her subscapularis. There was also some associated tendinous thickening, along with  subacromial bursal thickening and synovitis around the proximal bicep tendon sheath.

    This means Sarah's rotator cuff injury is not a surgical case. We are dealing with rotator cuff pathology and proximal biceps tendon pathology with an associated subacromial bursitis.

    Many of these findings may be present from the actual trauma. However, these findings are very likely to have been there for quite some time. 

    I’ve read studies demonstrating that if you have some small tearing in your symptomatic rotator cuff, you likely have small tearing in your pain-free other rotator cuff as well!

    Sarah has been unable to use her arm the way she would like to. Her rotator cuff has been injure for some time. Her body is recruiting muscles differently and her shoulder is not moving optimally.

    Since the rotator cuff's main job is to stabilize the joint, her joint has been 'unstable'. When she has been moving her arm, exercising, it was putting stress and strain on the other shoulder musculature, leading to pain and further injury.

    What steps do we take to recover from Rotator Cuff Injuries?

    We need to utilize in holistic approach to managing Sarah shoulder injury so she can get back to living life and working on her own terms and so she can get so she can enjoy her vacation paid for you only have eight short weeks. 

    Phase 1 - Rotator Cuff Injury Pain Relief

    This phase is all about pain reduction. It's hard to do much exercise or rehab if you're in a lot of pain. So we want to bring that that pain down as much as possible.


    Phase one typically takes roughly one to four weeks.

    Remember imaging it showed tendinitis, and subacromial bursitis? This means inflammation within the tendon sheath and bursa. 

    It is very likely that a lot of Sarah’s pain is coming from that inflammation. The constant aching. Referred pain down her arm is likely due to that inflammation. 

    Inflammation causes pain. 

    How do we reduce the pain? 

    Obviously medication prescribed from your family doctor is an option. Sometimes it's helpful, but don’t hold your breath. Medication also has a fun response to your gut, typically. 

    There are other effective strategies as well. Topical analgesic creams (Biofreeze, Voltaren, A5/35, etc. 

    Ice is nice. Using an ice pack 10 to 20 minutes at a time can be very helpful in desensitizing the area and reducing inflammation.

    A TENS machine can be quite helpful in reducing pain. TENS stands for Transcutaneous Electrical Neuromuscular Stimulation. It zaps you with electricity to help numb those pain nerves, interrupting them from sending pain signals to your brain.

    While this isn't going to fix the problem, it does help with pain reduction. So if we can reduce the pain that will help us be able to move which is then going to help get into healing with the healing.

    Gentle range of movement exercises such as Codman circles, walking, just moving your arm can be very helpful in reducing pain. Flushing that inflammation out of that glenohumeral joint. 

    Motion is lotion, and movement is key.

    Chiropractic manipulation of the spine and the glenohumeral joint can be quite helpful in these acute situations. While not curative at this point, it really helps desensitize the area and reduce pain .

    The last option in this acute phase is an injection. If the shoulder pain is extremely intense, due to bursitis an injection may be helpful. They stick a needle full of cortisone in that bursa which eliminates the inflammation. Steroids are fantastic reducing inflammation. If that subacromial bursa is the main source of her pain, a subacromial injection into that person to be life saving or at least pain reducing.

    The problem with this, is that often people will stop at phase one. They don’t progress to phase two, which its where we get into stopping the reason the inflammation got there in the first place!

    This is almost like drawing a beautiful picture, but only finishing half the picture

    Phase Two - Rotator Cuff Injury Rehabilitation

    Phase two is all about shoulder rehabilitation. The pain is significantly less but it's not completely gone. But now Sarah can actually use her arm and start to exercise it without it that wanting to chop it off. 

    Phase two of care typically takes between two to eight weeks long

    Now Sarah can start strengthening, mobility, and rehabilitative exercises. The goal in this phase is to improve the functionality, develop strength in those tissues and rehab that rotator cuff so it's able to do its job. Remember the rotator cuff’s job is primarily to stabilized the glenohumeral joint so it's can function optimally and not be sloppy and slosh around aggravate other tissues that cause injury and cause further injury and damage. 

    Sometimes it takes a little longer, depending on the severity of the rotator cuff injury. It isn’t to uncommon to take a year to go through the three phases.

    One of the problems that can happen when a muscle in the shouldergets injured is those muscles start to not work quite so well. And because you haven't been using them for a while, they start to get weaker and they start to atrophy. 

    Those neural those newer neural circuits between your brain and your and that area start to become a little that wiring starts to become a little thinner doesn't work quite so well. So one of the main goals of this phase is to get those rotator cuff muscles firing and to get them in coordination with all the other peri-scapular musculature. Remember the rotator cuff doesn't work in isolation. It works with all the other muscles as well.

    There are several ways we can get these muscles to fire, and several rehab exercises. We need to start these in an integrated fashion. 

    I cant tell Sarah to just go exercise your shoulder and then expect her to do it and do it correctly. No, we need to start at the bottom and then slowly work our way back up with some simple straightforward exercises. As she improves, they become more and more complicated and complex.

    First we may need to perform some myofascial therapy. This can help relax some of those tightened muscles, and fascial restrictions that have developed. This will allow more mobility through the shoulder girdle and glenohumeral joint. This may include the rotator cuff, latissimusdorsi, rhomboids, pecs, the neck region and essentially the whole upper quarter of your body.

    Oh, you thought we were just going to talk about the rotator cuff? If only it were that simple. The shoulder is like a tight knit community. If you mess with one of the structures, they all get mad. So we got to treat them all. Make them all happy. Get them all working together. Coordinated and balanced.

    Mobilization and manipulation of the cervical spine, thoracic spine, scapula, AC joint SC joint glenohumeral joint can all be beneficial.

    One of the main things that manipulation does aside from improved mobility is improved neuromuscular coordination. Manipulation causes a quick muscular stretch of the golgi tendon organs. This causes a relaxation of the muscles but also it causes this neurological rewiring. This neurological barrage or stimulus to the central nervous system - your brain- in the region that controls the shoulder. In essence, it gives you better neuromuscular control. 

    While some people believe manipulation just “puts things back in place”, it= doesn't quite work like that. It's not quite that simple.

    This is one of the reasons chiropractic care shines and can be quite as a huge part of recovering from shoulder and rotator cuff injuries. 

    In Sarah’s caase, after about 10 days we were through phase 1. She had about 4.5 weeks until her big trip.

    During phase two I saw her roughly twice a week. Provider her with her graded exercises over time. Performed myofascial release, manipulated her cervical spine, thoracic spine, shoulder girlde. And we also performed shockwave therapy. 

    After about two, she started noticing a significant reduction in pain. She said she felt about 80 to 90% better, but anytime she would do any excessive stress or straining or physical activities. That's when it really started to continue bothering her. 

    In Sarah’ case, it took a couple of extra weeks to improve neuromuscular coordination and to improve the endurance and conditioning of those muscles working correctly.

    By this time Sarah was all ready for her trip! She was significantly better, just noticing some discomfort periodically with certain awkward movements. 

    And good thing to! Because her flight was just a few days away.

    I recommended she have a great time on her trip, and that when she comes back we progress to phase 3, so we reduced the chances of this becoming a permanent problem for her.

    Phase Three - getting back to life 

    Phase one was all about pain reduction. Phase two was about improved mobility and function in daily activities. Phase three is about getting ready to take on life.

    Many people drop out after phase one. The pain is ‘mostly’ gone, and they figure they can deal with that.

    Next, many people drop out after phase two. It works for the most part, and that’s fine for some people. They don’t mind that the pain is likely going to come back, and they aren’t concerned about making a full recovery.

    Phase three is more for those who want to take on life without their shoulder getting in the way. For high achievers. For those concerned about their long term health, Trying to improve their overall health and wellbeing. Those looking for the edge…

    So while you are doing 80-90% better now, phases three its to get to 100% and beyond.

    Remember, the shoulder is extremely muscular, and extremely mobile. We need to get all these muscles working together, coordinated, fully rehabilitated, to really significantly reduce the chances of it becoming a reoccurring problem. 

    Typically, in this phase of care, I don't see patients nearly as frequent because they I show them what they need to do and they need to do it if they don't do it. They don't get better Simple as that.

    Some of the exercises you may have seen before, but they're not going to be so much the classic rehab type exercises. You can't just can't expect to move two pounds up and down except expect your shoulder to get stronger. You need to stress your shoulder, force it to get stronger. You also need to be doing some stretches to stretch out those tight muscles and improving your posture and balance. Typically these include the neck, pectorals group, biceps, latissimus dorsi, posterior deltoid and rotator cuff musculature.

    Exercises may include push ups, wall climbs various types of rows, pull downs, rear delt flies, exercises to strengthen the posterior delt and posterior rotator cuff musculature. Overhead presses, lateral raises Front Raises. bear crawls, back burners, KB swings, KB presses, bottom up presses


    The semi-regular ‘tune up’ is always helpful as well to help you recover between your rehab/ exercise sessions as well.

    How long is this phase take? 

    Typically this phase lasts one to three months. Sometimes longer. You will benefit from semi-regular ‘tune ups’, and also progression of your recovery programming. Because as you get better, it needs to get more challenging, so you continue to improve!

    In Sarah’s case, she came into the office for treatment about once every 3-4 weeks over 4 months. We had made significant improvement with her strength and mobility of her shoulder. She was now feeling better than ever!

    Now she is back to the gym, lifting more, faster. She is out climbing, riding, running. She is able to roll on the ground with her kids and do everything she wants! 

    IV. Holistic Approach to Recovery

    Explain the holistic approach to treating shoulder conditions.

    Emphasize that holistic care includes addressing not just the physical symptoms but also the emotional and mental aspects of recovery.

    Discuss the benefits of a multi-faceted approach that considers nutrition, exercise, stress management, and mental well-being.

    V. Dispelling the Myth of a "Life Sentence"

    People often think that shoulder strains and tears mean you can never fully recover. But that's not true! Just like with other health issues, it's possible to get better and live an active life again.

    When you hurt your shoulder, it might seem like you'll never be the same. It can hurt a lot, and it's hard to do things you enjoy. But our bodies are amazing, and they can heal with the right care. Doctors and specialists who focus on helping shoulders can make a big difference.

    To get better, you need to be committed, follow a plan, and believe that you can get back to the activities you love.

    Each person's journey is different, but with an expert to help guide you, you can regain your freedom again. You don't have to let shoulder injuries control your life.

    Getting Back to an Active Life:

    Shoulder injuries, like many health issues, shouldn't make you think you can never be active again. Our bodies are strong and can heal well with the right care. New knowledge and better healthcare approaches mean that you can improve and have an active life again.

    It's important to know that shoulder injuries, though tough, don't have to be a life-long problem. You can overcome these challenges with determination, guidance from experts, and the right approach. The journey may be hard, but the rewards of getting your full motion back and living without pain are worth it.

    By seeing healthcare professionals who focus on helping shoulders in a holistic way, you can work on your recovery. The right approach can help you regain your active life and inspire others by showing that getting better is possible.

    In short, shoulder injuries don't have to stop you from living the life you want. With the right care, you can heal and enjoy an active life again.

    VII. Collaborating with Healthcare Professionals

    Open communication with your healthcare team is a powerful tool, just as Sarah has exemplified in her journey toward better health. Sharing your experiences, concerns, and aspirations with your healthcare professionals is the first step towards achieving your health goals.

    By speaking openly and honestly, your chiropractic orthopaedic specialist will you with vital information you need to have a tailored treatment plan to your unique needs. They may need to refer you for imaging, to your medical doctor, to a physical therpist, athletic therapist, trainer, kinensiologist, or for injectionsn. Possibly to the surgeon. It depends on your unique siutation. 

    This collaborative approach ensures that your care is personalized, effective, and aligned with your aspirations. It allows your healthcare providers to better understand your preferences, concerns, and expectations, ultimately resulting in a more successful health journey.

    Sarah's proactive mindset and willingness to communicate have led her toward better health and well-being. In the same way, your active participation and open dialogue with your healthcare team can pave the way for improved health outcomes. Together, you and your healthcare professionals can work as a team, navigating the path toward your health goals with confidence and determination.. 

    Empower yourself! 

    Here are a few strategies to do so.

    1. Consult with Healthcare Professionals:

    Begin by seeking medical advice from a specialist - such as a chiropractic orthopaedic specialist - to get an accurate diagnosis and determine the extent of your rotator cuff injury. Understanding the severity of the injury is crucial for creating an effective recovery plan, and setting up realistic expectations.

    2. Manual Therapies:

    Begin getting manual therapy with someone who specializes in shoulder rehabilitation. Perhaps someone like your chiropractic orthopaedic specialist! Manual therapies, such as soft tissue therapy, mobilization, manipulation, shockwave therapy and rehabilitation exercises are key. They can help improve range of motion, strengthen the muscles, and alleviate your pain.

    3. Set Clear and Achievable Goals:

    Establish specific and measurable goals for recovery. This might include objectives like regaining full range of motion, reducing pain, or gradually returning to daily activities or sports. Ensure these are realistic! If you have a full thickness, full width tear and you need surgical repair, that is going to take longer than 1 week to recover!

    4. Consistency 

    Commit to daily rehabilitation exercises prescribed by your healthcare provider. If you don’t make this a staple in your day to day, I’m sad to say, you can kiss your shoulder recovery away. Enjoyed that rhyme? If you don’t stay consistent, you’ll enjoy that rhyme more than you’ll be enjoying your shoulder. 

    THIS is crucial for making a full recovery.

    5. Lifestyle Adjustments:

    Make necessary lifestyle adjustments to support your recovery. Avoid activities that worsen the pain or put strain on the shoulder. Ensure you are getting adequate rest and sleep to aid healing.

    6. Nutrition and Hydration:

    Consume a balanced diet rich in nutrients that support the body's healing process. Staying well-hydrated is also essential for overall well-being. You are what you eat. And if you eat garbage, your healing capacity will be less than ideal.

    7. Stress Management:

    Manage stress through relaxation techniques, mindfulness, or meditation. Stress can exacerbate pain and hinder the healing process. As Bob Marley said, “Don’t worry, be happy”.

    8. Regular Check-Ins with Healthcare Providers:

    Schedule follow-up appointments with your health care provider - your chiropractic orthopaedic specialist - to assess your progress. As things improve, they will adjust your treatment plan accordingly, so you can continue to make strides forward.

    9. Knowledge is power!

    By educating yourself, like yo uare right now, about rotator cuff injuries and rehabilitation you can make better decisions. Understanding your condition and treatment options can empower you to make informed decisions and take an active role in your recovery.

    Taking an active role in recovery from a rotator cuff injury requires dedication, patience, and perseverance. By setting clear goals, tracking progress, making lifestyle adjustments, and seeking the support of healthcare professionals, you can improve your well-being and regain optimal shoulder function. Remember that recovery is a gradual process, and with the right mindset and approach, it's possible to achieve a success!

    How to Recover From A Rotator Cuff Injury

    Shoulder, and rotator cuff injuries can be challenging to recover from, but it can happen! Using a holistic approach, one that your chiropractic orthopaedic specialist can help guide you with, is a great starting point. 

    Injuries, strains and tears do not mean a life sentence of pain and suffering. Using a holistic approach is your best bet to get better, and you can get better! Recovery is possible.

    If you are dealing with a shoulder, or rotator cuff injury its time you take action, and get started on your healing journey.

    Although Sarah made a great recovery in the end, if she was more proactive initially, she could have avoided a lot of pain, and such a long recovery process. 

    If yo tare looking for improved shoulder health and improved quality of life, get started today!

    Your Choice: Rotator Cuff Relief or...

    Are you ready to take charge of your shoulder health? I would like to invite you to reach out to my office. As chiropractic orthopaedic specialist, I specialize in shoulder health. With expert guidance, you can finally start your path of healing.

    You are not alone. This may be your first time, but I've seen hundreds of shoulders just like yours, no matter how 'bad' it may seem now.

    Together, we can help you make a full recovery. Your story can inspire others to achieve optimal shoulder health and well-being as well. 

    Call us or send an email today to get started on your shoulder recovery journey today.

    Dr. Joseph Tanti

    About the author

    I am a husband, and father, love dogs AND cats, and I am a chiropractor. I help people recover from pain, and injuries and improve their overall health and well-being, and have fun doing it!

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